En Bloc Aortic Resection for Bulky Metastatic Germ Cell Tumors

0022-5347/95/1536- 1849$03.00/0 JOUKNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOCICAL ASSOCIATION, INC

Vol. 153, 1849-1851,June 1995 Printed in U.S.A.

EN BLOC AORTIC RESECTION FOR BULKY METASTATIC GERM CELL TUMORS ROSEMARY KELLY, DONALD SKINNER, ALBERT E. YELLIN

FRED A. WEAVER* Medicine, LJS Angeles, California

AND

From the Departments of Surgery and Urology, University of Southern California School of

ABSTRACT

Between 1989 and 1993, 97 patients with stages B3 andor C nonseminomatous germ cell tumors of the testes underwent induction chemotherapy followed by retroperitoneal lymph node dissection. Of these patients 6 (ages 22 to 41 years) had gross extension of tumor into the aortic adventitia a t operation, which necessitated en bloc aortic and, on 3 occasions, iliac artery resection for complete tumor removal. Aortic continuity was restored by a woven Dacron tube or bifurcated graft. All grafts were covered with omentum. There were no postoperative vascular complications. Pathological study of the residual retroperitoneal disease demonstrated that 2 patients had mature teratoma only, 2 had mature teratoma with occasional nests of immature teratoma and 2 had residual yolk sac, embryonal or choriocarcinoma elements. The latter 2 patients underwent postoperative salvage chemotherapy with varying combinations of bleomycin, etoposide, ifosfamide and cisplatin. At 4 to 55 months 4 patients were disease-free, while 2 died of metastatic disease. No problems related to the aortic reconstruction have occurred. This small experience demonstrates that, if necessary, complete surgical en bloc extirpation of bulky metastatic germ cell tumors and the aortdiliac artery can be performed safely with a satisfactory long-term outcome. KEY WORDS:testicular neoplasms, lymph node excision, aorta, drug therapy

The initial treatment of all patients with bulky metastatic germ cell tumors of the testes is 3 to 4 cycles of cisplatin, etoposide and bleomycin. Most patients will respond with a decrease in biochemical tumor markers to normal or near normal values. However, despite biochemical evidence of tumor necrosis most patients have residual bulky retroperitoneal disease on followup computerized tomography (CT). It is uncertain whether patients with proved seminoma require resection of residual disease but those with nonseminomatous germ cell tumor of the testes benefit from complete surgical removal of all residual retroperitoneal carcinoma. Surgical management of bulky metastatic stages B3 and/or C nonseminomatous germ cell tumors of the testis following induction chemotherapy involves en bloc resection of all tumor plus involved organs and retroperitoneal lymph node dissection. Cure rates of 60 to 80% have been reported following this therapeutic approach.' In patients whose primary tumor is composed largely of embryonal, yolk sac or choriocarcinoma elements, the extent of residual retroperitoneal disease is usually fairly modest but those with significant teratomatous elements often have extensive residual disease in the retroperitoneum, occasionally intimately involving and/or encasing the great vessels (aorta or vena cava). Extension of tumor to major vascular structures, such as the aorta, poses major judgmental and technical challenges if total en bloc resection of tumor is to be achieved. We previously reported our experience with en bloc vena caval resection in 12 patients.2 We currently report the results in 6 patients whose residual retroperitoneal disease encased and involved the aorta to such a degree that resection of the aorta and/or iliac arteries was necessary for complete tumor removal. MATERIALS AND METHODS

Between 1989 and 1993, 97 patients with nonseminomatous germ cell tumors of the testis underwent retroperitoneal Accepted for publication October 7, 1994. * Requests for reprints: University of Southern California School of Medicine, 1510 San Pablo St., Suite 415, Los Angeles, California 90033-4612.

lymph node dissection at our university after having first received induction chemotherapy, which consisted of cisplatin, etoposide and bleomycin. Of this cohort 6 patients (6%) required concomitant infrarenal aortic resection (3 with bilateral common iliac artery resection as well due to the extensive vascular involvement by the tumor). The approach for retroperitoneal lymph node dissection has been described previously. In all patients undergoing aortic resection an 8th or 9th rib thoracoabdominal incision was used. The small and large bowels were mobilized superiorly to expose the retroperitoneum. Early identification and dissection of the superior mesenteric artery was performed, and dissection of the renal vessels was often tedious. The distal iliac vessels (external and internal) were mobilized to permit vascular control. The lateral limits of dissection were defined by identifying both ureters. The inferior vena cava was then skeletonized with ligation of the lumbar veins. Once the inferior vena cava was free, and the proximal and distal limits of dissection were established, the patient was given systematic anticoagulation with 5,000 units of heparin intravenously and the aorta was divided. The resection was completed by sharp dissection of posterior attachments from the anterior spinal ligament, with posterior penetrating lumbar arteries and veins controlled as they penetrate the psoas muscle adjacent to the sympathetic trunk. The aorta was reconstructed with a 14 or 16 mm. woven Dacron bifurcated or tube graft. Soft tissue coverage of the graft to isolate it from the small and large bowel was accomplished by mobilizing greater omentum and placing it over the graft. The age of the 6 patients ranged from 22 to 41 years: 4 had stages B3 to C and 2 had stage B3 nonseminomatous germ cell tumors of the testis. The primary pathological status is listed in the table. Preoperatively all patients had a normal lower extremity pulse examination. Preoperative CT in all patients documented extensive retroperitoneal disease with poor definition between the aortic w d and tumor (see figure). In each case the final decision to resect the aorta was made intraoperatively.

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EN BLOC AORTIC RESECTION FOR BULKY METASTATIC GERM CELL TUMORS En bloc aortic resection for nonseminomatous -germ cell testis tumor Postop. Pathological Findings

pt. No,

Primary Pathological Finding (stage)

Operation

1

Embryonal Ca (B3 to C)

2

Terotoca. (B3 to C )

3

Chorioca. (B3)

Retroperitoneal lymph node dissection, rt. orchiectamy, resection lung metastasis, aortic tube graft Retroperitoneal lymph node dissection, It. nephrectomy, It. orchiectomy, mediastinal dissection, aortic tube graft Retroperitoneal lymph node dissection, aortic9 iliac graft Retroperitoneal lymph node dissection, resection lung metastasis, aortidiliac graft Retroperitoneal lymph node dissection, resection lung metastasis, aortic graft Retroperitoneal lymph node dissection, aortic/ iliac graft

4

Teratoca. (B3 to C)

5

Teratoca. (B3 to C)

6

Teratoca. (B3)

CT shows encasement of infrarenal aorta by large tumor and loss of definition of aortic wall.

RESULTS

Mean hospital stay was 9 days (range 7 to 11). There were no perioperative deaths and no vascular complications related to aortidiliac resection or graft placement. There were 3 postoperative complications: 1 patient had neuropraxia of the right femoral nerve that resolved within 7 days without sequelae, 1 had persistent hypertension following a renal artery injury and 1 had an inguinal hematoma requiring exploration. Pathological evaluation of the operative specimen demonstrated mature teratoma in 4 cases, 2 of which also showed focal immature teratoma. Residual embryonal, yolk sac tumor or choriocarcinoma was present in 2 patients (see table), both of whom underwent salvage chemotherapy with combinations of ifosfamide, cisplatin, etoposide and bleomycin. Both patients died of metastatic disease a t 4 to 55 months (mean 2 5 ) . The remaining 4 patients were free of disease a t 4, 18,24 and 55 months. No vascular graft related complications have occurred.

Salvage Chemotherapy

Followup (mos.)

Embryonal yolk sac Ca

Yes

Dead I41

Mature teratomdimmature teratoma

No

Alive (181

Mature teratomdimmature teratoma Mature teratoma

No

Alive (55)

No

Alive (24)

Mature teratomdpulmonary chorioca. Mature teratoma

Yes

Dead (51

No

Alive ( 4 )

primitive elements have a 50% risk of failure due to metastatic disease. Retroperitoneal lymph node dissection with complete tumor resection is critical to patient management, since no preoperative test precisely determines whether the residual retroperitoneal mass is necrotidfibrotic, contains teratoma or consists of residual primitive c a r ~ i n o m a Furthermore, .~ mature teratoma is not a benign process; it tends to grow locally and may undergo malignant degeneration into sarcoma. At our institution salvage chemotherapy is used when residual embryonal, yolk sac or chorionic elements are found in the operative specimen. Thus, retroperitoneal lymph node dissection not only provides local control of residual disease but also is a guide to the necessity for additional chemotherapy. The dissection of bulky metastatic nonseminomatous germ cell tumors of the testis can be extremely difficult when the aortic adventitia is involved. A parallel situation occurs when the inferior vena cava is encased with tumor or thrombosed secondary to tumor involvement. In several reported series the inferior vena caval involvement necessitating vena caval resection made tumor resection a technically easier operation, achieving complete removal with minimal complications.236-7While it is usually possible to skeletonize the aorta, it occasionally can be so difficult that arterial injury results. None of our 6 patients had clear preoperative indications of aortic involvement except for loss of definition of the aortic wall on CT. However, this finding is common in patients with nonseminomatous germ cell tumors of the testis. Thus, the decision to include the aorta in a n en bloc resection was made intraoperatively, and based on extensive tumor invasion into and encasement of the aortic wall. Technically, aortidiliac replacement with a synthetic prosthesis is straightforward using modern vascular techniques. Of importance is the need to cover the aortic graft completely with soft tissue to prevent subsequent bowel erosion with the development of a n aorta-enteric fistula. Since the retroperitoneal soft tissue is largely removed following retroperitoneal lymph node dissection, greater omentum is usually necessary for complete graft coverage. When sufficient greater omentum is not present, a rectus abdominis pedicle flap is probably the best alternative for graft coverage.8

DISCUSSION

Most patients with stages B3 and/or C nonseminomatous germ cell tumors of the testis following induction chemotherapy of 3 to 4 cycles of cisplatin, etoposide and bleomycin have evidence of residual retroperitoneal disease.3 Those with significant teratomatous elements in the primary tumor usually have the most extensive disease on CT. Histological examination of the tissue obtained by retroperitoneal lymph node dissection demonstrates that 40%of the specimens consist of only scar and necrosis, 40% of mature teratoma and 20% of residual primitive elements.* Patients with only necrosis or teratoma- in the operative specimen do extremely well without additional chemotherapy. However, those with residual

CONCLUSIONS

Our experience demonstrates that, when necessary, aortic resection and reconstruction following retroperitoneal lymph node dissection can be performed safely, and permit complete removal of the tumor. Given the significant risk of tumor recurrence when residual tumor is left, the relative simplicity of aortic graft placement and the long-term absence of vascular complications, we submit that metastatic nonseminomatous germ cell tumors of the testis firmly adherent to the aortic wall are treated optimally by aortic resection and vascular graft replacement.

EN BLOC AORTIC RESECTION FOR BULKY METASTATIC GERM CELL TUMORS REFERENCES

1. Skinner, D.G. and Leiskovsky, G.: Management of early stage nonseminomatous germ cell tumors of the testis. In: Diagnosis and Management of Genitourinary Cancer. Philadelphia: W. B. Saunders Co., chapt. 34, pp. 516-525, 1988. 2. Ahlering, T. E. and Skinner, D. G.: Vena caval resection in bulky metastatic germ cell tumors. J. Urol., 142: 1497, 1989. 3. Herr, H.W., Toner, G. C., Geller, N. L. and Bod, G. L.: Patient selection for retroperitoneal lymph node dissection after chemotherapy for nonseminomatous germ cell tumors. Eur. Urol., 1 9 1,1991. 4. Kulkarni, R. P.,Reynolds, K. W., Newlands, E. S., Dawson, P. M., Makey, A. R., Theodorou, N. A,, Bradley, J., Begent, R. H., Rustin, G. J. and Bagshawe, K. D.: Cytoreductive surgery in disseminated non-seminomatous germ cell tumours of testis. Brit. J. Surg., 7 8 226, 1991. 5. Qvist, H.L., Fossb, S. D., Ous, S., Hoie, J., Stenwig, A. E. and Giercksky, K.-E.: Post-chemotherapy tumor residuals in patients with advanced nonseminomatous testicular cancer. Is it necessary to resect all residual masses? J. Urol., 145: 300, 1991. 6. Donohue, J. P., Thornhill, J. A,, Foster, R. S.,Rowland, R. G. and Bihrle, R.: Resection of the inferior vena cava or intraluminal vena caval tumor thrombectomy during retroperitoneal lymph node dissection for metastatic germ cell cancer: indications and results. J. Urol., 146 346, 1991. 7. Toner, G. C., Panicek, D. M., Heelan, R. T., Geller, N. L., Lin, S. Y., Bajorin, D., Motzer, R. J., Scher, H. I., Herr, H. W. and

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Morse, M. J.: Adjunctive surgery after chemotherapy for nonseminomatous germ cell tumors: recommendations for patient selection. J. Clin. Oncol., 8: 1683, 1990. 8. Mehran, R. J., Graham, A. M., Ricci, M. A. and Symes, J. F.: Evaluation of muscle flaps in the treatment of infected aortic grafts. J. Vasc. Surg., 15: 487, 1992. EDITORIAL COMMENT

The authors have parlayed their expertise in aggressive resection of residual masses after chemotherapy for metastatic testis tumor to include successful en bloc resection incorporating the abdominal aorta. They deserve our respect for courageously challenging apparent defeat by “unresectable” residual tumor. Their 2 failures in this report occurred in patients whose residual tumor was malignant, 1of whom had resectable pulmonary masses that proved to be unsuspected choriocarcinoma. Until there are reliable preoperative tests showing that residual masses contain carcinoma, this aggressive team approach by skilled urological oncologists and vascular surgeons is important to define the limits of curability. Long-term followup is necessary to validate the correct indications for such vigorous treatment. James M. Holland Department of Urology Northwestern University Medical School Evanston Hospital Euanston, Illinois